1 of 7

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning on or after 01/01/2020 Coverage for: Individual / Family | Plan Type: DHMO SEL : KP VA Gold 500/20/Dental

2101 East Jefferson Street, Rockville, MD 20852

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see www.kp.org/plandocuments or

call 1-855-249-5018 (TTY: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.HealthCare.gov/sbc-glossary/ or call 1-855-249-5018 (TTY: 711) to request a copy.

Important Questions Answers Why This Matters:

What is the overall deductible? $500 Individual / $1,000 Family

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Preventive care and services indicated in chart starting on page 2.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No. You don’t have to meet the deductibles for specific services.

What is the out-of-pocket limit for this plan? $6,400 Individual / $12,800 Family

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Copayments on certain services, premiums, balance-billing charges, and health care this plan doesn’t cover.

Even though you pay these expenses, they don’t count toward the out–of–pocket limit.

Will you pay less if you use a network provider?

Yes. See www.kp.org or call 1-855-249-5018 (TTY: 711) for a list of network providers.

This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

Yes, but you may self-refer to certain specialists.

This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

2 of 7

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event Services You May Need

What You Will Pay Plan Provider

(You will pay the least)

What You Will Pay Non-Plan Provider

(You will pay the most) Limitations, Exceptions, & Other Important

Information

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness

$20 / visit, deductible does not apply Not covered Copayment waived for children under age 5

Specialist visit $40 / visit, deductible does not apply Not covered None

Preventive care/screening/ immunization

No charge, deductible does not apply Not covered

You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, blood work)

$40 / visit, deductible does not apply Not covered None

Imaging (CT/PET scans, MRIs) $300 / test Not covered None

3 of 7

Common Medical Event Services You May Need

What You Will Pay Plan Provider

(You will pay the least)

What You Will Pay Non-Plan Provider

(You will pay the most) Limitations, Exceptions, & Other Important

Information

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.kp.org

Generic drugs

$20 / prescription at Plan Pharmacy and Mail Order, deductible does not apply; $30 / prescription at Participating Pharmacy, deductible does not apply

Not covered Up to a 30-day supply; Up to a 90-day supply for 2 copays. No charge, deductible does not apply for preventive drugs or contraceptives.

Preferred brand drugs

$50 / prescription at Plan Pharmacy and Mail Order, deductible does not apply; $60 / prescription at Participating Pharmacy, deductible does not apply

Not covered Up to a 30-day supply; Up to a 90-day supply for 2 copays. No charge, deductible does not apply for preventive drugs or contraceptives.

Non-preferred brand drugs

$100 / prescription at Plan Pharmacy and Mail Order, deductible does not apply; $110 / prescription at Participating Pharmacy, deductible does not apply

Not covered Up to a 30-day supply; Up to a 90-day supply for 2 copays. No charge, deductible does not apply for preventive drugs or contraceptives.

Specialty drugs

50% coinsurance / prescription at Plan Pharmacy and Mail Order, deductible does not apply; 50% coinsurance / prescription at Participating Pharmacy, deductible does not apply

Not covered Up to $300 max per 30-day supply or up to a $600 max per 90-day supply.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) $250 / visit Not covered None Physician/surgeon fees $40 / visit Not covered None

4 of 7

Common Medical Event Services You May Need

What You Will Pay Plan Provider

(You will pay the least)

What You Will Pay Non-Plan Provider

(You will pay the most) Limitations, Exceptions, & Other Important

Information

If you need immediate medical attention

Emergency room care $300 / visit, deductible does not apply

$300 / visit, deductible does not apply Copayment waived if admitted as inpatient

Emergency medical transportation No charge No charge None

Urgent care $40 / visit, deductible does not apply

$40 / visit, deductible does not apply

Non-plan providers are covered only outside the service area.

If you have a hospital stay

Facility fee (e.g., hospital room) $500 / admission Not covered Emergency admissions covered for non-plan providers.

Physician/surgeon fees $40 / admission Not covered Emergency services covered for non-plan providers.

If you need mental health, behavioral health, or substance abuse services

Outpatient services

$20 / individual visit, deductible does not apply; $10 / group visit, deductible does not apply

Not covered None

Inpatient services $500 / admission Not covered None

If you are pregnant

Office visits No charge, deductible does not apply Not covered

Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Childbirth/delivery professional services $40 / admission Not covered None Childbirth/delivery facility services $500 / admission Not covered None

If you need help recovering or have other special health needs

Home health care No charge Not covered None Rehabilitation services $40 / visit, deductible

does not apply Not covered Inpatient: None. Outpatient: Limited to 30 visits each for PT/OT/ST/year.

Habilitation services $40 / visit, deductible does not apply Not covered

Limited to 30 visits each for PT/OT/ST/year. Early Intervention: No visit limits for certain children under age 3. ABA not covered.

Skilled nursing care $500 / admission Not covered Coverage is limited to 100 days / stay Durable medical equipment No charge Not covered None Hospice services No charge Not covered None

5 of 7

Common Medical Event Services You May Need

What You Will Pay Plan Provider

(You will pay the least)

What You Will Pay Non-Plan Provider

(You will pay the most) Limitations, Exceptions, & Other Important

Information

If your child needs dental or eye care

Children’s eye exam

No charge / Optometrist visit, deductible does not apply; $40 / Ophthalmologist visit, deductible does not apply

Not covered Coverage limited to one exam/year.

Children’s glasses No charge, deductible does not apply Not covered

1 pair of glasses / year or 1st purchase of contact lenses / year or 2 pair / eye / year medically necessary contacts (from select group of frames and contacts)

Children’s dental check-up No charge, deductible does not apply Not covered Discount fees apply to other services. $10

office visit copay applies / visit. Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Cosmetic Surgery • Hearing Aids

• Long Term Care • Non-emergency care when traveling outside the

U.S.

• Routine Foot Care • Weight Loss Programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic Care (30 visits / condition / year.

The visit limit applies separately for Habilitative and Rehabilitative services)

• Dental Care • Private Duty Nursing

• Infertility Treatment • Routine eye care (Adult)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is shown in the chart below. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the agencies in the chart below:

6 of 7

Contact Information for Your Rights to Continue Coverage & Your Grievance and Appeals Rights: Kaiser Permanente Member Services 1-855-249-5018 (TTY: 711) or www.kp.org/memberservices Department of Labor’s Employee Benefits Security Administration 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform Department of Health & Human Services, Center for Consumer Information & Insurance Oversight

1-877-267-2323 x61565 or www.cciio.cms.gov

Virginia Bureau of Insurance 1-877-310-6560 or www.scc.virginia.gov/boi Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-855-249-5018 (TTY: 711). Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-855-249-5018 (TTY: 711). Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-855-249-5018 (TTY: 711). Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-855-249-5018 (TTY: 711).

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

7 of 7

The plan would be responsible for the other costs of these EXAMPLE covered services.

Peg is Having a Baby (9 months of in-network pre-natal care and a

hospital delivery)

Mia’s Simple Fracture (in-network emergency room visit and follow up

care)

Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well-

controlled condition)

The plan’s overall deductible $500 Specialist copayment $40 Hospital (facility) copayment $500 Other copayment $40 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800

In this example, Peg would pay:

Cost Sharing Deductibles $500 Copayments $1,500 Coinsurance $0

What isn’t covered Limits or exclusions $60 The total Peg would pay is $2,060

The plan’s overall deductible $500 Specialist copayment $40 Hospital (facility) copayment $500 Other copayment $40 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400

In this example, Joe would pay:

Cost Sharing Deductibles $0 Copayments $1,500 Coinsurance $0

What isn’t covered Limits or exclusions $60 The total Joe would pay is $1,560

The plan’s overall deductible $500 Specialist copayment $40 Hospital (facility) copayment $500 Other copayment $40 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $1,900

In this example, Mia would pay:

Cost Sharing Deductibles $500 Copayments $800 Coinsurance $0

What isn’t covered Limits or exclusions $0 The total Mia would pay is $1,300

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

ACA-CATLAR (2020) Landscape

NONDISCRIMINATION NOTICE Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser Health Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as:

• Qualified sign language interpreters • Written information in other formats, such as large print, audio, and accessible electronic formats

• Provide no cost language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages

If you need these services, call 1-800-777-7902 (TTY: 711) If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail or phone at: Kaiser Permanente, Appeals and Correspondence Department, Attn: Kaiser Civil Rights Coordinator, 2101 East Jefferson St., Rockville, MD 20852, telephone number: 1-800-777-7902. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

HELP IN YOUR LANGUAGE ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-777-7902 (TTY: 711). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-777-7902 (TTY: 711).

ACA-CATLAR (2020) Landscape

).TTY :711( 7902-777-800-1 اتصل برقم. ، فإن خدمات المساعدة اللغویة تتوافر لك بالمجانالعربیةإذا كنت تتحدث :ملحوظة (Arabic) العربیةƁǎsɔ́ɔ̀ Wùɖù (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m̀ Ɓàsɔ́ɔ̀-wùɖù-po-nyɔ̀ jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔ̀ ɓɛ́ìn m̀ gbo kpáa. Ɖá 1-800-777-7902 (TTY: 711)

Bengali)

中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-777-7902（TTY：711。 -1-800-777 (TTY: 711) اگر بھ زبان فارسی گفتگو می کنید، تسھیالت زبانی بصورت رایگان برای شما فراھم می باشد. با توجھ: (Farsi) فارسی تماس بگیرید.7902

Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-777-7902 (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer:1-800-777-7902 (TTY: 711).

Gujarati)

Kreyòl Ayisyen (Haitian Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-777-7902 (TTY: 711).

Hindi)

Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ 1-800-777-7902 (TTY: 711). Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-777-7902 (TTY: 711). 日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-777-7902（TTY: 711 まで、お電話にてご連絡ください。

한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-777-7902 (TTY: 711)번으로 전화해 주십시오.

ACA-CATLAR (2020) Landscape

Naabeehó (Navajo) D77 baa ak0 n7n7zin: D77 saad bee y1n7ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-777-7902 (TTY: 711.) Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-777-7902 (TTY: 711). Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-777-7902 (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-777-7902 (TTY: 711). Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-777-7902 (TTY: 711). ไทย (Thai) เรยีน: ถา้คณุพดูภาษาไทย คณุสามารถใชบ้รกิารชว่ยเหลอืทางภาษาไดฟ้ร ีโทร 1-800-777-7902 (TTY: 711).

-1-800-777 (TTY: 711) اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کریں خبردار: (Urdu) اُردو7902.

Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-777-7902 (TTY: 711). Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-800-777-7902 (TTY: 711).